Payer Solutions
Insights-driven, transformative
healthtech consulting.
Payer Solutions
Insights-driven,
transformative
healthtech
consulting.
Delivering Business
Configurable Solutions
A team of seasoned unconsultants dedicated to guiding national and regional health plans navigate through complex problems and facilitate the implementation of simple and effective solutions.
Our unconsultants approach prioritizes collaboration and unconventional perspective, working alongside you as a cohesive team. We bridge the gap between Business and IT with proven industry expertise in delivering scalable, business-driven technology and process solutions. We provide solutions that harness emerging technologies to optimize businesses and improve patient outcomes and experiences.
Solutions We Offer
Utilization
Management
Management
Care
Management
Management
Claims
Matching
Matching
Clinical Decision
Support
Support
Utilization
Management
Management
Ensuring appropriate and efficient use of medically necessary healthcare resources, services, and treatments while optimizing administrative processes and costs.
Our comprehensive approach enables health plans to enhance operations and have fiscal oversight of their members’ services.
Automation of Benefit Discovery
Automate and auto-populate the database of members to efficiently retrieve relevant information and details across various systems, eliminating manual data retrieval and streamlining the process for customer advocates and their teams.
Clinical Decision Support Systems
A decision engine that analyzes and determines the auto-approval or need for further review of service requests, expediting the decision-making process and addressing potential data gaps upfront to optimize efficiency and minimize the involvement of high-cost resources.
Role-Based Visualization
Our solution aggregates data and access control, allowing users to access specific data sets that pertain to their role, increasing the accuracy of decision-making.
AI in Auth Process
AI presents a natural fit where outdated human decisions can be automated through ML models trained on established criteria. This scalable and agile approach reduces administrative costs and optimizes workflow to improve member satisfaction.
Care
Management
Management
Delivering patient-centered quality care by leveraging data insights to ensure that patients/members receive appropriate and timely care to prevent their healthcare costs from escalating.
Our comprehensive solution manages and determines the most suitable next steps, personalizing care delivery, cost containment, and enhancing patient outcomes across the healthcare continuum.
Characterization
Utilizing valuable insights from large amounts of data to assist healthcare professionals in timely intervention and personalized care, improving efficiency, and enhancing communication to prevent further complications.
Case Management Solutions
Prioritizing health conditions and facilitating the routing of patients to appropriate interventions. Eliminating the need to outsource for specialized services by orchestrating and coordinating case management efforts by guiding decision-making and optimizing patient routing.
AI in Predictive Risk Stratification
Leveraging the power of AI to generate risk scores and recommend timely intervention and prioritize resources to improve patient engagement, reduce unnecessary utilization, and improved outcomes.
Claims
Matching
Matching
Enabling claims matching process through integrating and aligning authorization and claims data to support payment accuracy. This ensures that the healthcare organizations are accurately paying for the services that have been authorized.
Our comprehensive solution performs checks and balances to validate claims and bridges the gap between utilization management and claims systems.
Simplification Process
Automating claims processing by streamlining workflows and creating configurable exception handling based on organization’s unique needs. Thus, increases the efficiency of adjudicating claims by simplifying exception handling process and only showing relevant information.
Personalize Dashboards
Provide custom screens for financial services unit to identify and address pending claims, enhancing decision-making efficiency.
Data Manipulation/Data Processing
Validating claim data against utilization management systems/authorization systems for accuracy and consistency, eliminating manual effort and human error.
Clinical Decision
Support
Support
Automating clinical decision-making processes to provide nimble and agile capabilities to clinicians in specialty chronic condition management Oncology, Diabetes, etc. Eliminating the complexity and challenges associated with rules engine configuration by creating a single and reliable source of truth for medical necessity.
The clinical Decision Support system as a consolidated source ensures consistency and accuracy across any healthcare organization, streamlining and simplifying the authorization process at scale.
Authorization and Regimen Management
Enabling authorization process to manage multiple regimens and approval criteria across diverse health plans, ensuring accuracy and variation evaluation prior to making a decision.
Lifecycle Tool
Enabling initial shell authorization with collected data and running it against member benefit eligibility and other decision factors.
Decision Engine Tool
Streamlining workflow process for regimens approval by cross-checking them against preapproved criteria of each health plan, taking traditional treatment plans, drug approvals, and alternatives into consideration prior to automating a decision.
Auditable/Review Component Tool
Oversight of workflow to verify regimen variation for the authorization process. The tool provided a mechanism to have an audit of changes and impact across the organization.
Utilization Management
Ensuring appropriate and efficient use of medically necessary healthcare resources, services, and treatments while optimizing administrative processes and costs.
Our comprehensive approach enables health plans to enhance operations and have fiscal oversight of their members’ services.
Automation of Benefit Discovery
Automate and auto-populate the database of members to efficiently retrieve relevant information and details across various systems, eliminating manual data retrieval and streamlining the process for customer advocates and their teams.
Clinical Decision Support Systems
A decision engine that analyzes and determines the auto-approval or need for further review of service requests, expediting the decision-making process and addressing potential data gaps upfront to optimize efficiency and minimize the involvement of high-cost resources.
Role-Based Visualization
Our solution aggregates data and access control, allowing users to access specific data sets that pertain to their role, increasing the accuracy of decision-making.
AI in Auth Process
AI presents a natural fit where outdated human decisions can be automated through ML models trained on established criteria. This scalable and agile approach reduces administrative costs and optimizes workflow to improve member satisfaction.
Care Management
Delivering patient-centered quality care by leveraging data insights to ensure that patients/members receive appropriate and timely care to prevent their healthcare costs from escalating.
Our comprehensive solution manages and determines the most suitable next steps, personalizing care delivery, cost containment, and enhancing patient outcomes across the healthcare continuum.
Characterization
Utilizing valuable insights from large amounts of data to assist healthcare professionals in timely intervention and personalized care, improving efficiency, and enhancing communication to prevent further complications.
Case Management Solutions
Prioritizing health conditions and facilitating the routing of patients to appropriate interventions. Eliminating the need to outsource for specialized services by orchestrating and coordinating case management efforts by guiding decision-making and optimizing patient routing.
AI in Predictive Risk Stratification
Leveraging the power of AI to generate risk scores and recommend timely intervention and prioritize resources to improve patient engagement, reduce unnecessary utilization, and improved outcomes.
Claims Matching
Enabling claims matching process through integrating and aligning authorization and claims data to support payment accuracy. This ensures that the healthcare organizations are accurately paying for the services that have been authorized.
Our comprehensive solution performs checks and balances to validate claims and bridges the gap between utilization management and claims systems.
Simplification Process
Automating claims processing by streamlining workflows and creating configurable exception handling based on organization's unique needs. Thus, increases the efficiency of adjudicating claims by simplifying exception handling process and only showing relevant information.
Personalize Dashboards
Provide custom screens for financial services unit to identify and address pending claims, enhancing decision-making efficiency.
Data Manipulation/Data Processing
Validating claim data against utilization management systems/authorization systems for accuracy and consistency, eliminating manual effort and human error.
Clinical Decision Support
Automating clinical decision-making processes to provide nimble and agile capabilities to clinicians in specialty chronic condition management Oncology, Diabetes, etc. Eliminating the complexity and challenges associated with rules engine configuration by creating a single and reliable source of truth for medical necessity.
The clinical Decision Support system as a consolidated source ensures consistency and accuracy across any healthcare organization, streamlining and simplifying the authorization process at scale.
Authorization and Regimen Management
Enabling authorization process to manage multiple regimens and approval criteria across diverse health plans, ensuring accuracy and variation evaluation prior to making a decision.
Lifecycle Tool
Enabling initial shell authorization with collected data and running it against member benefit eligibility and other decision factors.
Decision Engine Tool
Streamlining workflow process for regimens approval by cross-checking them against preapproved criteria of each health plan, taking traditional treatment plans, drug approvals, and alternatives into consideration prior to automating a decision.
Auditable/Review Component Tool
Oversight of workflow to verify regimen variation for the authorization process. The tool provided a mechanism to have an audit of changes and impact across the organization.
Featured Case Studies
Insurance provider serving 119 million people at every life stage, offering a comprehensive suite of commercial, Medicare, and Medicaid plans and clinical, behavioral, pharmacy, and complex-care solutions.
Claims Management
Developed a pre-authorization-to-claims matching solution to streamline the processes for commercial, Medicare, and Medicaid plans. Our solution lowered costs and improved customer satisfaction for the payer's clients.
Largest customer-owned health insurer in the U.S. and the fourth largest overall, which operates Blue Cross and Blue Shield Plans and various affiliates and subsidiaries to expand access to high-quality, cost-effective health care to 17 million members across multi-states.
Care Management
Launched a Care Management product for employers, individuals, families, and Medicare/Medicaid plans, and managed the clinical components of planning, execution, and operational readiness, ensuring a successful go-live and stabilization.
Largest customer-owned health insurer in the U.S. and the fourth largest overall, which operates Blue Cross and Blue Shield Plans and various affiliates and subsidiaries to expand access to high-quality, cost-effective health care to 17 million members across multi-states.
Utilization Management
Delivered a custom Utilization Management solution for Medicare and Medicaid programs, seamlessly migrating users across multiple sites without disrupting customer service.
Largest customer-owned health insurer in the U.S. and the fourth largest overall, which operates Blue Cross and Blue Shield Plans and various affiliates and subsidiaries to expand access to high-quality, cost-effective health care to 17 million members across multi-states.
Change Management and Training
Implemented a strategic Change Management program, migrating 2,500+ clinical staff across multiple sites. The solution serves as a blueprint for future processes and technology updates.
